Rehabilitation of the COVID-19 Patient with Dayna McCarthy, DO and Noah Greenspan, DPT


It’s for the most part tests are coming back negative in terms of cardiac workup, pulmonary workup and patients were being told that in the worst cases that it’s all in their head, there’s nothing wrong with them. And, and and that there’ll be fine. They just have to kind of keep going on with life. Right. But, but as we all know that these symptoms can be in circumstances very debilitating. So from there, you know, we kind of said at Mount Sinai that we were really going to focus on being patient centric in terms of care. So this is a huge unknown, right? This is a novel virus. Science takes awhile, right. Science takes time. So that said, we’re trying to implement techniques to try to get patients feeling better safely in this circumstance. And so for us, at least from my perspective it is not research based. So we do collect data, but we are not research focused, we’re patient focused. So everything revolves around trying to get patients feeling better.


So you mentioned the technology aspects of it and the monitoring. So what are the capabilities that you have for remote monitoring and who are they available to?


Yeah, so, so right now with, we haven’t yet enrolled our unveiled the chronic COVID remote monitoring, that should be coming in the next one to two weeks. I believe, and please, no one quote me on this because I, I don’t understand the technicalities of, of working inter interstate. So with New York, you know, anybody in New York insurance wise, you can call in, you can get enrolled in this, and then you’ll be connected with a clinician who will be monitoring you. And what it is is daily input on a platform of your symptoms and how you’re feeling. And then that person is going to be reviewing that. And as we start getting an understanding more in terms of how patients are responding with different symptomatology and different inputs, then that’s a quick line of access for us to give good medical advice, right. And guidance towards patients towards feeling better. I believe I’d be done out of state again. I just, I don’t know the particulars on that, so I don’t want to be quoted on that.


Gotcha. So if you could just talk a little bit about symptoms. So if you could talk a little bit about acute COVID, which you were seeing, what you’ve seen, sort of you know, as things have progressed and what you’re seeing now, as far as, you know, long haulers


Or so, so in acute COVID patients, again, these, these are ones that were hospitalized and not hospitalized. Just as all over the news, there, there are individuals who are experiencing temperatures, they’re individuals who are not but high temperature for either a short period of time or even going on weeks. It was possible. And when I say temperature, that’s a hundred 0.3 degrees or higher, that’s what we consider a temperature. People who are having cough acutely, this isn’t, this would be a more mild kind of form of this people having sore throats, people having loss of smell and loss of taste individuals with a lot of gastrointestinal upset be that bloating, diarrhea, acid reflux, all seen in the acute phase. And almost every system would, could be affected in the acute phase to be fair.


Which unfortunately is transitioning to the aftereffects of probate as well. Individuals that were hospitalized tend to have more respiratory distress. So these were individuals who required some oxygen to help them breathe. They’re O two stats were coming down in very low levels. So they were getting that type of support. There were individuals who were admitted because they had some problems with their kidneys. So their kidneys could be affected again in the acute phase, in severe illness. And there were some individuals who had issues in terms of the effects on their, on their blood, so to speak. So either clotting, that sort of thing. And we saw that in the acute phase as you well know, there was a lot of back and forth in terms of drugs that we could utilize to be helpful. Right. and that was again, trying to solve and be helpful in, in a crisis situation.


As we well know, we yet have we yet have a medication or drug for an acute phase that is really indicated or helpful, right. So a lot of them have been talked about and discussed, but I cannot say with, with good certainty and confidence that there is medications that in the acute phase are in and of themselves very helpful. So dexamethazone is one for somebody who’s intubated, right? Who is, it has been shown to kind of decrease that and help in terms of outcomes. Right. But for individuals, other than that, there really has not been much, and it’s been very individually based. So no one medication has been able to help everybody, so to speak in the acute phase.


What is death dexamethazone? What is that?


That’s an episode is a steroid. It’s actually quite familiar to me in my pre COVID life. So it’s a particulate steroid and what it is is an antiinflammatory medication. It is used for a multitude of reasons. But in this case, again, they, the theory and why it’s used as, as an antiinflammatory agent. And how is that administered?


Is that something that’s Ivy or oral or through it


Come on his own as usually an intermuscular type of injection. Gotcha.


Okay. And when did you start to get the sense that Hey, we’re not in Kansas anymore, and this is not the 14 day you know, kind of respiratory flu cold virus that everybody was talking about.


Yeah. So I actually wouldn’t say that I ever got that only because and again, this is just from a clinical perspective, it seems to be that individuals that were severely affected, meaning those who had to be hospitalized actually seem to be recovering better in, in a large percentage of patients, then individuals who had a more mild acute illness, viral illness. And again, we don’t know the reason behind that we’re still researching and trying to identify what the immune response is to this virus. And a lot of work is being done behind the scenes on that. We just don’t have answers yet. So there are some patients who, who that may have been the case for, right. There’s a huge spectrum of individuals on how they’re responding to it. And, and why that is so, so I would say in terms of this other grouping of patients, right, that has having prolonged symptoms, I mean, end of March, April being the big rush of when most people were infected, I’d say by probably early June, we started, you know, coming to this kind of conclusion that, Hey, these symptoms are not getting better for patients and they’re still suffering very significantly.


Almost debilitating in some instances, right, where you can’t, you can’t do your daily activities of daily living, right. Let alone, you know, work and things like that. So so, so I would say probably early June was when we started to kind of circle around this. And that’s when I started seeing patients in regards to kind of chronic effects of COVID and these prolonged symptoms,


You know, I, I have a sense that at any other time in history the majority of patients that went to the ER probably would have been admitted. And I also feel that, you know, like just a show of hands, how many people here were hospitalized. So pretty small, pretty small number, you know, as far as, as we’re looking at. And I wonder if you have a, an opinion as to like, have these people been hospitalized, you know, or admitted to the ER, went to the hospital, went to the ICU where they’re being monitored. Do you have a sense of, of whether or not their course would have been very different?


I don’t. And, and to be fair. So in individuals with more mild to moderate acute illness, a lot of you know, what we look at when we’re somebody up clinically, what may have been negative for the most part anyway. So I don’t know if they would have been kept, right. So you know, in terms of criteria for admission to hospital, I don’t know if they would have met that criteria even. So so it’s hard for me to weigh in other than that, you know, the problem is right. We were not a problem, but, you know, vital signs are vital for a reason, right. They, they tell us how we’re doing right. In terms of in terms of the organs that are necessary for us to sustain life. So a lot of credit has to be given to that. And a lot of faith has to be put into that. That does not discount the fact that people were feeling terrible. Right. but even in with, let’s take the flu for example. Right. So, I mean, there’s a huge spectrum of how people suffered from the flu, right. And even in those cases, it’s a very small percentage that we ended up hospitalizing for that, but it doesn’t mean that their acute illness is not terrible, but they’re just able to sustain themselves at home with the proper supportive care.


And how do you both in the acute phase and kind of now, as we start to get people into rehab, how do you do delineate between kind of who’s dangerous and who’s just very uncomfortable.


Yeah. So that’s a good question. I mean, if, are we talking about acute? Are we talking about the chronic, you know, because


Like, for example let’s say let’s start with acute. So acute, you know, what, what my experience was was a lot of people went to the ER EKG test X, right? EKG was normal or TAC, a cardiac, you know, tachycardic, but sinus tacky, chest X, Ray was clear,


Just ads for maintains


What you said was maintained. And this patient was more than likely to be discharged home.


Yup. Yeah. And that would still be the case. Right. Even now, and I don’t think anything would change. And that’s, because again, we still don’t understand enough about how this virus is affecting the immune system. Right. So you know, even, even the tests that we’re doing in terms of blood work and things like that, there’s a high degree of variability depending on, on the patients. So the ones who are more severe and then hospitalized right with, with the pneumonia, the viral pneumonia, the inability degree of needing that, that support in terms of restoration, their levels may or may not have been higher. I mean, I was seeing that in any acute admitted patients as well. So you know, I, I would say, yeah, in that case, I don’t think much would change for the acute patients even now until we, until we understand a little bit more about it.


So if we could go a little bit system system, so what blood work like is, is important for people to get and what might, what, you know, let’s go for like the big bang you know, big bang for your buck, information testing. So what blood work do you want to see?


So for me, right, so again, and I don’t, I would never never step in here and say, I’m a cardiologist, right. Or pulmonologist, that’s not my place in this. So for me, it’s actually less about blood work. I actually am relying on specialists to give a clearance for them to get started in programs for us, because we don’t know. And because they’re the ones doing research in that system specifically. So there are things that sometimes can be elevated, but that’s at the discretion of the cardiologist or the pulmonologist being, being the individual who is specialized in that. So what we are requiring, at least from my perspective is an echocardiogram before anybody starts in a rehab protocol with, with me, or, you know, individuals working with me just to be safe because in a very, very small percentage of patients, right. The heart muscle can be affected and we just don’t. We want to make sure we don’t miss anybody in that regard.


And is that a resting echo or a stress echo?


So it can be both, a lot of times it’s resting because people can’t tolerate the stress echo you know, either cardiac stress testing or a stress echo, whether it’s chemical or, you know, movement movement-based patients are not able to tolerate.


Gotcha. And what other cardiac tests do you want to see? Like, ideally


For me, that’s the main one. I, I, you know, some people are doing stress tests, some people are doing halter monitors, but for the most part, all of that’s coming back negative. So as long as I have a negative stress test then I can go from there if, I mean, echo, I apologize. So if there’s positive findings and obviously that’s going to be a different or divergent path for treatment, right. Because you have underlying condition that’s happening there. So, so that’s what I would say in that regard.


I try to get people to at least get like a 24 hour halter if not longer. And you’re right. And, you know, in a lot of the experiences they are coming back negative. But to me that coming back negative is a gift. And, you know, like so many patients like say, Oh, I’m sitting on the couch. And I see a patient send me videos of their pulse socks. Like they think I haven’t seen like, you know, big movie, you know, company movies before, and I want to watch their pulse ox videos. And it’s like, I’ll see a heart rate go like 75, 80, 91, 10, one 30, one 50, and then cycle back down. So to me, I want to know, well, what is that? Is it sinus tack? Is it, you know is it that they have into a fib or something like that? With the majority of my patients who have anything remotely cardiac, I want to see echo agree with you. And I also want to see something related to the electrical activity.


Yeah. So most of the patients will already have an EKG if they don’t, but definitely the starting point. Right. And yeah, I agree with you that sometimes, you know, obviously EKG is just a moment in time, but again, in terms of birth theories, at least from my perspective, medically speaking, I’m okay to clear somebody to start in terms of rehab protocols with the echo because you, you will see that variability that variability in the heart rate is so common. It’s probably the most common thing that I’m seeing amongst patients with these prolonged symptoms. And that is usually a sinus tachycardia. And that’s just going to say there, the cardiologist looks at you and says, okay, well, you know, this is you being deconditioned. Right. But that’s not the, you know, for us, it’s more than that. Right. So so that said you know, this heart rate variability from our perspectives is part of this autonomic nervous system being dysregulated.


Yeah. We just actually, coincidentally met with your team a little while ago. And I agree. I don’t think I’ve seen one single patient where I would say it’s a cardiovascular or hemodynamic limitation. I think any time it is heart rate or rhythm, you know, it’s, it’s almost always dysautonomia.


Yeah. Well, Oh, so I’m gonna pause you there. And I’m going to say, please don’t use the term because I, I also am very, I’m very specific and not putting a label on anything at this point. So dysautonomia is a term that indicates a chronic kind of syndrome. And right now we’re not, we’re not there yet. So I, I would never say dysautonomia, I would say autonomic dysregulation, a post viral autonomic dysregulation and in newness, incited, autonomic dysregulation. All right. So, and again, because, because we can’t say that right


Point taken, I just wrote it down and you will never hear me say, Hmm,


I know for our audience, I love it. I love it. So because if somebody says to me, even as a patient, right, says to me, you have dysautonomia, I would start, I would start freaking out because that’s a forever kind of thing. Right. You just labeled me as having a syndrome that I’m going to have for the rest of my life, where I’m only able to make the symptoms a little bit, you know, better and try to manage them. Right. But that, that is not, what’s what we’re saying is happening right now. We don’t, we can’t say that, but what we can is the autonomic nervous system is dysregulated. I liken it to like, so you had a, you had an illness, right? And you had this immune response to this illness. We don’t quite understand. And it looks like there’s a ton of variability in how our immune system is, is choosing to respond a side effect of that is that the autonomics have gone kind of haywire. It’s like opening up a fuse box and everything’s sparking at you. Right. It’s just, it’s going awry. So our job is to try to calm the systems down and give positive feedback and input to regulate them again. And with that comes, decrease in symptoms and feeling better.


Well, that’s actually a much more hopeful description of it. So I’m happy to hear you say that, and I’m happy to be corrected on that. So that’s awesome. What does an initial visit look like with you?


Yeah, so so for the most part, patients are coming to me through different resources. I’m part of the postcode peer program at Mount Sinai. So I will get patients that way. And the reason I’m alluding to how patients come to me or, or, or discussing that is that most often they will have a, I’ve seen a lot of specialists before they get to me in the rare instances where they haven’t, then it’s my job to send them out to the appropriate ones. So it’s very patient specific. So when I do the intake, I am actually very fortunate that I’m given which is very unusual in this day and age, decent amount of time to sit with patients and really understand what their experience has been. And so the amount of time, and yeah, so I’m going to, I believe this, I’m given 45 minutes to see a patient, which is unheard of.


Yeah, really? Yeah. I consider that the tip of the iceberg. I mean, we have some patients who are sitting for two hours and then I need to have a drink in between patients joking. I’m just kidding everybody. Just kidding. I don’t drink.


Right. And again, like, it’s understandable. I, the, the amount of, of anxiety that surrounds them, and that’s also another huge important part to talk about is whether you were an anxious person or not baseline, you cannot control these external factors that surround us nowadays. And I don’t care whether you had COVID or not. You could have had a common cold to have it. The environment is tremendous stress on your body. And we very well studied how stress affects the system. Right. and affects every part of the system. So one of the components that I think really has to be focused on in terms of getting patients feeling better is, is really this idea of minimizing the amount of stress that people are, are undergoing and facing. Right. And really trying to, to increase a more optimistic, positive narrative around this, rather than this anxiety of unknowns, which is very easy to fall down kind of this rabbit hole of right.


And then have worked up about it. I mean, I I’m in the medical field, I’m a physician. I can be guilty of that myself too. Right. Like, and from from a physician’s perspective, it’s hard sitting here not having the answers. Right. It’s hard not having that. It’s hard admitting that. Right. But it’s, it’s, you know, it’s the idea of accepting and committing and working together. Right. All of us as a team to try to try to get people feeling better. So part of that is on the patients too, right. Is kind of having this outlook right. And saying, I want to get better. I there’s, there’s no reason that I shouldn’t get better. Right. you know, and if there’s other underlying causes that that doctors will be working with you to, to get those underlying issues optimized. Right. But in the setting of these prolonged post COVID affects that, you know, it’s going to take a while.


So no matter what, because of the external environment, which we do not have control over, it is an uphill climb. It just is. And you know, to be forced to be isolated, the other stressors that happen, you can’t see your loved ones. You can’t hug them. Right. You can’t spend time with them. You in some instances, whether it’s you or someone, you know, or love, they’ve lost their job right now, your job is might be giving you a hard time because you’re not feeling good. And they’re like, Hey, well, all these tests, nothing’s wrong with you. Right. So there’s all these oppressive forces. Right. And, and, you know, that’s not the illness, that’s not the effects of COVID, but it certainly is making it so much harder to feel better.


It’s like a constant assault of on there, on your senses. You and I were talking briefly before about the, the effect of, of Facebook and some of these support groups. You know, and, and again, without criticism, that’s not, that’s not the point of what I’m saying. But one of the things that, you know, we try to get people to understand is that resting doesn’t necessarily mean watching TV, resting and healing doesn’t necessarily mean being on Facebook, resting doesn’t mean looking up 27 studies you know, related to your illness, you need to rest so you can heal.


And some of that, the opposite of resting, right. So breast, right. And I think this is what you’re getting at. There’s two forms, there’s physical ruts, right. And there’s cognitive rest. So, you know, if we’re not allowing our brains to rest, right, and we’re not actively every day, trying to be cognizant of the different factors that are affecting us in that regard and the stress they’re putting on us, then, then you know, we’re doing ourselves a disservice, right? So you know, a lot of my advice to patients is, and I do understand it. And you know, all these support groups are born out of people, not knowing. So they’re going to come together. That’s what we do. Right. So doctors don’t have answers. We’re going to go to each other and we’re going to at least have this community where we can talk about what we’re feeling and not that’s completely appropriate.


One would expect that the problem is when that becomes overwhelming and now you, as the individual suffering are losing control, right. So what happens is you go on to all of these things, right? You hear all the talk it’s circling around you, and then, and then you, you, you don’t have control over yourself. Right. And then the anxiety component of it takes hold of you. And you’re driven by that. Right. And as soon as that happens, that’s when you start, you know, the physiological effects of that are a huge, massive increase in inflammation in your system. So when I say, you know, it’s not, it’s doing yourself a disservice. I mean, it, your body cannot handle that. And that’s going to make you feel worse. So, yeah, it’s certainly not the whole picture, right. I’m not saying if we just decrease anxiety, you’re going to get better. Absolutely not. What I’m saying is having that increase in anxiety is certainly making it much, much harder.


Yeah. And there’s a lot of research that shows that, you know, like by retelling the tale of this event or by, you know, kind of thinking about it and then, you know, and then again, yeah, absolutely. So let’s go back to the 45 minutes. So I come to see you for 45 minutes after we got some Botox and some lipo where do we go from there?


So, so when you come in to see me, right, it’s a lot about your story. So that’s important for me. And from our perspective, again, being patient centric, right. And when we talk about this dysregulation of the autonomic nervous system, right. That for me means that I have to understand certain components of your life what’s happening now. Right. So we’re going to go through different things. We’re going to go through your dietary habits. We’re going to go through your sleeping patterns, right. We’re going to go through what, you know, how much you’re able to exert yourself, what that looks like, what, what exacerbation of symptoms happen if you push yourself too much if you’ve been keeping a diary about things, right. And what have you noted when that happens? I’m talking about social stuff, right? So that I alluded to like what kind of support system you have all different things. And then of course, going through each different system, right up the body for systems reviews, what do you call it? A review of systems to, to of course go through and of course your past medical history. So it’s just a very thorough intake in terms of understanding the patient, right. You asked the patient and what could be contributing. And then therefore it allows me to implement some different tools and get you the help you need.


And are you solely seeing patients remotely now, or are you seeing patients in the office as well?


I’m seeing patients both ways. I see patients in the office one day a week, and then I see remotely as well.


Gotcha. And can we back up a little bit, you mentioned dietary, right? So what, if any, is the relationship between diet and Kobe?


Yeah. Sorry. I’m not a direct relationship per se. Right. But when we talk about inflammation, right. And how that doesn’t help you feel better, all of that’s connected. So right now what we’re doing is trying to guide and advise towards an anti inflammatory type diet. So, and again, that can change depending on the patient, what that looks like, right. If they need different inputs or if there’s other background medical stuff, I think he needs. Right. but when we’re talking about a general antiinflammatory diet we’re discussing things like decrease in sugar, right. So maintaining a minimal sugar intake, a decrease in simple carbohydrates. So that’s like your, your breads and your cookies and things like that. And decreased in fried foods. Yeah. It’s, winkies are out,


Twinkies are out there Friday and okay. Gotcha.


And I think you would see the feedback that you definitely get from patients is again, this is always a spectrum, right. But many patients will say, if they eat those kinds of foods, they tend to feel not great after it. Right. And you can say neither does anybody else really? Because you have a kind of crash after you eat something. Right. But it tends to be exacerbated in this setting. So the idea is that if we optimize each of these systems, right, and you can maintain this and be very regimental about that, right. That we will start getting you feeling better.


And you mentioned also sleep. What, what relationship are you seeing? Are you seeing COVID affect sleep and sleep affect COVID


Oh, my goodness. Insomnia with COVID is like one of the number one things that I’ve seen anywhere from patients, you know, and it’s for a multitude of reasons. Right? So individuals having the chest, chest discomfort or pain at night, or feeling like their heart’s racing and it may wake them up or the feeling of shortness of breath during the night may wake them up all the way to the, you know, poor sleep hygiene, which is a term that we use to discuss your habits. Before you go to bed to prepare you for good sleep. Two things like, you know, just having in some or where they, they get up in the middle of the night. They just, their body is all of a sudden on this, on this circadian rhythm where they’re just awake at two 30 in the morning and I can’t go back to sleep. So a multitude of different things. So the idea, again, it’s very well known and very well studied, right. That if you do not get enough sleep, your body’s ability to heal itself is then decreased. Right. So it’s certainly something we want to optimize. And you mentioned people


Waking up in the middle of the night with a racing heart, short of breath. I hear that from tons of people, what’s the mechanism behind it.


Again, it’s still hard to say, right. So if we talk about this autonomic dysregulation, you know, there, you could theorize that because you’re in the soup or the supine position, right. That you’re pumping mechanism. Right. And now you have, when I say pumping back in as a mind, referring to your blood flow in your body, right. So the autonomics right. Are not regulating well. So, so maybe there’s just some firing with that, you know that, you know, I, I don’t have a very specific pathophysiology about that because again, it’s COVID, and we’re just not quite sure. Right. So,


And when that happens, somebody wakes up in the middle of the night, they’re having a racing heart, they may have chest pain, they may have shortness of breath. How do they know if they’re okay? Or if they need to take some type of, you know, medical intervention at this moment


Measures. Yeah. So, so here’s what I say. If you have previous party at condition, right. Or, or pulmonary condition, right. That can also affect your heart that is something to be taken, taken more seriously and underlying condition. That’s not well-maintained right. So that’s first and foremost to, especially in this patient population who most have had a significant workup. Right. And they’re still experiencing the symptoms, but everything has come back negative. Right. I want patients to try to have the ability to kind of, you know, sit up or lie there and say, you know, okay. I, I know that in terms of anything that will adversely affect me to the point, right. Where my viability is at risk, right. Meaning you could die from it, right. That’s, that’s not what’s happening in this instance and utilizing breath. Right. So this is where we get into some of this breath work in terms of control over the autonomic nervous system and know that’s where, that’s where your expertise comes in here. So this is one of the huge parts of our initial kind of treatment approaches for trying to get patients to feel better. So getting, giving these tools of utilizing breath work in these instances to try to decrease symptoms like that.


Incidentally, ladies and gentlemen, we did post last Saturday and Sundays breathing exercises. So feel free to check those out. So let me ask you this just, just your opinion, you know from a perspective, point of view how effective are the telehealth visits as compared to an in person visit?


Oh, that’s a great question. So they are effective. I personally I like to see patients in person, right. It allows me to do a complete physical exam and, you know, objective measures that we’re utilizing right now are difficult because most of the sub specialists and everybody doing that has done a thorough workup in terms of tests and, and, you know, we still don’t yet have sensitive objective measures. But that doesn’t rule out the fact that my physical exam is very important for me in terms of getting a whole picture on a patient. That doesn’t mean that a telehealth visit is not effective. Right. Cause a lot can be accomplished with that. And I think it’s worth having a visit no matter what, rather than no visit. Right. So if I booked out to a certain time, you’re better off seeing maybe a telehealth, right. So I can get the picture and get you started on stuff and see how that goes.


And when you’re seeing people in person, I’m like, what are you doing in terms of you know, protection? What are you wearing? And I mean, that only in a PPE perspective,


So Mount Sinai has very strict protocols. So I’m down at 10 union square, which is part of the post COVID care program where I see post COVID. We are required to wear, I wear protective eyewear and we’re required to wear a face mask. Most of us are wearing it and 95 plus the surgical mask. And then we always glove up whenever we would never touch a patient without gloves. And also if I’m listening to heart and lungs, there’s always a glove that goes over my stethoscope. So I’m never making direct contact with patients that way.


What do you put on first, your end 95 or your surgical masks?


Always the end 95 goes first


Surgical mask over protects your in 95, correct? Yep. Yeah. I like the way you think I do the same thing. Okay, cool. What what are you most worried about? Like what do you worry most about in terms of seeing patients?


Oh, be a little bit more.


Okay. So like a patient comes to you, what are your, let’s say top three priorities in terms of making sure they’re okay. And getting them back on the right track.


Yeah. So it depends on the patient, right. If a patient is coming to me and they, they haven’t seen anybody else before, right. Or it’s been very limited. Right. of course the, the pulmonary and cardiac aspect of that right. Is a higher concern for me. And I want to make sure once I, I can kind of have that categorized and I feel comfortable with the workup that’s been done right. Then I can move forward from there. Secondly, I think, and I was alluding to this too, for me understanding the, the psychological stressors surrounding a patient, not feeling well is very important because as I said, we can do everything till we’re blue in the face. Right. So, no, you can have so many sessions with the patient, but unless that component is well supported and taking care of, and unless I know the patient’s in the driver’s seat, right. So they have control in there. They’re really kind of, you know, working to manage it, but it’s not overwhelming them. Right. So it’s taking over their life. That is a huge priority for me because if it’s taking over somebody’s life, then no matter what we do patients, aren’t, they’re not going to feel better. So that is pretty


Show of hands. How many people feel overwhelmed and like it’s taking over your life. Okay. Happily, not happily for you guys that raised your hands, but the percentage is not massive, which is great. So we got to work on you guys that raised your hands. You mentioned for the heart, you want to see an echocardiogram. I mentioned, I want to see a halter or longer. What about the lungs? So pain, most patients have gotten chest X rays, most checks, tax rate is, are clear. Anything else you want to see?


You know, some patients will have pulmonary function tests, but unless you have a history of asthma you know, or some underlying pulmonary disease, I know those don’t come up positive. So again, I also don’t want patients having to undergo extraneous stuff, which also is going to make them feel worse because, Oh, there’s another test that telling me nothing’s wrong with me when I feel terrible. Right. So based on what we know to be coming back, that’s not an absolute criteria for me. Like I said, it’s patient dependent. So but the cardiac one is, is the primary goal for me to have clearance with.


Gotcha. I have not seen this a lot, but I’ve seen it in a handful of cases where patient didn’t have a known respiratory issue before, but does now. So for example, I’ve definitely seen people who have pulmonary fibrosis and scarring after a bad pneumonia. But recently I saw somebody who had an obstructive pattern. So sort of like a chronic bronchitis slash as Maddick type of, of pattern. Are you seeing that in people where they didn’t have an issue before and now they do?


No. I had an individual with mild to moderate acute illness. I haven’t really seen that. So I guess I would query back in that individual, what was the, what was the acute illness like? Was it a mild to moderate?


Well, you know, that’s a relative term, I would say more moderate, so they weren’t hospitalized, they weren’t on a ventilator. But you know, it was moderate enough that, you know, it wasn’t pleasant


Then I would say back to, you know, it depends on the history. Right. So if they don’t have overt, but that’s where getting a very thorough history comes into hand. Right. So were they a smoker? Right? Did they, do they have obstructive sleep apnea? Is there something else that might be going on in the background, right. That predisposes them to have that kind of clinical outcome.


Gotcha. And are there any tests specific for let’s say like a post viral dysregulation of the autonomic nervous system,


Not to date. There are not, you know,


Gotcha. I’m going to call that dance from now on, because I’m not going to say that every time. Okay. So there’s no test. So it’s basically symptom related and ruling out other things.


It is. Yep. But the good thing is, you know, at least with Sinai, so we we’re, we’re on the forefront of investigation for objective measures. And, and again, through the efforts of dr. David Patrina, we do have the ability to get likeminded people all over the world kind of contributing on a scientific front. So, you know, as soon as we get stuff, you know, we will start to implement that and be collecting data to see if there’s any, any changes or variability with the inputs that we’re doing from a rehab perspective.


Nice. And what about the neurosystem? Are there tests that you feel are valuable? I know it’s dependent upon the patient. Don’t don’t give me that one again, but it is, but as a general rule, are there things that you want to see to rule out a stroke or things of that nature?


Again, unfortunately, I am going to give you that one, but that’s where, that’s where the, like the, the physician examination right. And encounter comes into play because it is patient specific. I mean, I can give you many examples or not many, but I can give you examples of, of interesting things that happened as a result of COVID the effects of COVID. Right. But I I, you know, that is patient specific and in very rare cases, for the most part, what we’re seeing is a lot of, so numbness, tingling feeling like muscle for stipulations, right. Or that kind of pins and needle type feeling in the skin or hot and cold sensations happening or feelings of weakness in certain areas. And all of this, there is nothing that has been coming back positive and in any specific patient grouping from an overall perspective.


So like for example, muscle weakness. Okay. So recently I saw a patient who reported left sided weakness, numbness in the face and things like that. So is that somebody that you would like, is that something you would work up for other, or you’re comfortable saying that it’s dams?


It depends. Right. So it depends that just come on suddenly. Right. So I need more information about it. Is that progressing right? It does. My exam reveals something that makes me more concerned, right. If I go through and do a thorough nerve exam, like cranial nerve exam, right. And I’m testing motor I’m testing sensation, right. That’s where this physical exam becomes important. It helps me decide in terms of what further workup might be necessary there. In cases where there is a concern, you are definitely seeing more of a progression of symptoms. It’s not kind of a static, right. So, and when I say progression, that doesn’t mean the waxing and waning cause a lot of individuals are experiencing that. Right? So the symptoms may change slightly over a large period of time. But in this timeframe they’ll feel it some days it’s more, some days it’s less,


I’m going to ask you one more question, then we’ll go to audience questions. So after your time spent with the patient, you’ve done a thorough exam, you’ve done a review of systems, physical exam, if they’re in your place, what happens next?


Yeah. So then they usually I have, so we go over a plan, right. So that’s why everyone’s there, right. To try to get better. What can you do? Docs get me feeling better. And that’s where we circle back around. Right. And we try to assess each of those different systems and optimize them. Again, if there’s any further workup that I think is indicated, that’s when we make the plan for that and either refer them or I send them for different studies. Then that’s also where we start integrating this. If they’re a cleared current from a cardiac perspective for certain rehab programs, right. So such as yours. And that’s when we’ll get them integrated with that breathwork being the primary initiative for me is to get everybody started on a breath work protocol, because that is the number one input for your autonomics. And the example I like to give for that, which you may or may not do, but in the office is just a simple feeling of radial pulse, right? Taking a breath in, not too deep, because breathing is difficult for all, for patients, right. At this point, but holding it and seeing how your heart rate actually slows down when you hold your breath. And that is a prime example of how breathing right. And your pulmonary system is so closely related to your cardiac symptoms or in your cardiac system.


I do have one other question. So you mentioned kind of numbness, tingling, weakness. Those are things that we hear a lot. Something that I’ve not heard very often in my career is sort of like this buzzing or vibrating inside you, you have a sense of what that might be


Again, I think it’s all nerve ending. So we do get this and patients who have kind of like a peripheral neuropathy or things like that, but in this case, because it’s the nerves, right. Everything’s kind of fair game. So having that symptom is not surprising to me necessarily that symptom associated with other things maybe, but that’s patient specific.


Gotcha. Okay. So let’s go to some other questions.


Noah, I’m just going to ask you for a two minute break, if you don’t mind and I will


Let’s do it. Let’s do it. Yeah. All right. So anyone anyone have any questions so far comments, Dawn?


I mean, I think I have a, I have an appointment with dr. Mccarthy on Tuesday Mount Sinai. I know, I didn’t realize this. I believe


It’s the same person. It probably is. All right. We’re going to take a two minute breather. Okay. So everybody just find a comfortable position in your chair. And I would like you to close your eyes if you’re comfortable doing that. And we’re going to start with breathing in for a count of two and you can blow out for as long as you would like. And these are gentle, nothing forced breathing in through your nose. Let’s breathe in, in, and then nice and gently blow out through pursed lips. And it doesn’t matter how long that exhalation takes. So let’s go, It’s breathing, going in and relax, breathing in in, And relax. And if you like, when you take your breath in just nice and gently, bring your head back as you breathe in for two. And then as you blow out to bring your head down and your chin towards your chest, you may feel a little stretch in your neck as you do that, raising your head up as you breathe in in, and blow it out gently. And one more time breathing in for two And blow it out.




Just take a little break and we are going to start by if you’re comfortable breathing in for three. Okay. If you find that breathing in for three is too much stick with two. So let’s breathe in two, three, and blow Easy breathing in two, three is your head comes up, stretching your neck and low Breathing in two, three, and low




And again, breathing in two, three and relax. Nice, quiet, normal breathing




If and only if, and when you are ready, feel free to open your eyes and return to the room with calm and just sort of get your bearings again. Anyone feel different after that Rose, anyone want to share how they feel differently? Feel free to unmute. I feel calmer. How many people feel calmer? So that was just, you know, 10 to 12 breaths, right? So that’s something that you can do whenever you want. You’re feeling like things are getting out of control and remind yourself that you have a tool that you could use there. Anyone else, Wendy, you can unmute


Notice that putting my chin down to my chest when I’m breathing out. Yep. It, it helps stop that horrible cough because breathing out is my problem. I can breathe in all I want. It’s breathing out. It’s so hard. And that’s the first time you’ve told me that and I’ve done it and it definitely helps. I don’t cough, exhale.


Well, I didn’t want to give you all the tricks. The first time we spoke. I wanted to, I wanted to leave a little excitement in our relationship. Yeah. I have more. Don’t worry. Anyone else?


Can I ask about sleeping positions? I’m sure. Cause I’ve read a lot, obviously. I’m English. Hi, to a couple of my UK colleagues I can see are on board. But we read a lot recently in our support groups, the UK support groups from people who have said, particularly you, you compress your chest. You can press the lungs against the heart and other organs, if you are sleeping in a particular way. And so I have started sleeping on my side and using a pillow to keep myself on my side all the time. And I’ve been told never to lie on my back, but apparently it’s great to learn your front. Would you agree with that?


I’m going to say it depends on the individual I’m mean I learned that from dr. Mccarthy. but, but I would say yes and no. Okay. I’d say there, it depends. Okay. The answer to most questions these days is maybe right. So we could give you a definite maybe, but there’s different functions that occur depending upon your position. So as an example, when you’re lying on your back, what happens? So you have, first of all, when you’re lying flat, you have what we call increased venous return. So what that means is that blood from your lower body comes up due to gravity and it’s now in our upper body. Right. And what that does is that increases the workload on the left ventricle. So for some people that could make you uncomfortable, it doesn’t make everybody uncomfortable, but it could make you uncomfortable. If you have any type of left ventricular problem, like congestive heart failure, or you have any type of, you know, valve issue with either your aortic valve or your mitral valve, there could be a situation there I’m lying on your side.


Okay. What that does is that causes the abdominal contents to kind of lean over to the side and that clears the way for the diaphragm. So lying flat. Also, if you think about it like a rubber band, right? So like lying flat, the rubber band is stretched out, right. And that’s going to be the tightest. So if you want to take the breath that is going to, you know, it’s going to make it a little tougher for you. When you’re leaning forward like this, while you’re compressing a little bit, that’s also giving you a little Slack. The reason why lying on your, on your stomach has taken on such a big kind of role in COVID is because, you know, this is called proning. So a lot of the people who came into the hospital were dropping their saturations significantly. They were having a hypoxic episode and what they found was that groaning was very helpful in helping people elevate their oxygen levels.


And you know, when it comes to the heart and the lungs and the circulatory system, there’s something called ventilation and perfusion. So ventilation is air movement and oxygen delivery and profusion is blood delivery, right? So when you move or any position that you’re in, generally air is going to rise and liquid or blood is going to fall with gravity, right? And ideally what you want is you want the areas that are well oxygenated to also be well perfused so that you have a nice matching of ventilation and perfusion. There are people who have something called ventilation perfusion mismatch. So for example, if you had you know, you had blood coming to the area, but no air was coming to the area. Then that is not very beneficial. Cause the blood coming for a pickup, but there’s no supply there. Right. And likewise, if you had air coming to the area, but there was no blood coming there, which is sort of the case in like a pulmonary embolism.


Well, that’s not good because that air is there. It’s waiting to get on the train, but the train is not available. There’s no seats on the train. So I would say there’s no absolutes with it. The other thing is that if you’re talking about secretions then secretions position is very important also because if you think of it like this, let’s say some mucus in the upright position is also going to go down, right? So like if I had a bottle of ketchup here, I wanted to put ketchup on something, well, I can shake it. I could tap it. I could do whatever I want to it, but I put it in the right position that no catch-ups going to come out. So when you’re lying on your left side, as an example, you’re draining the right face. Most particularly when you’re lying on your, on your right side, you’re draining the left base and there are different positions for each for each segment. And that concludes our halftime show. Dr. McCarthy is back. Let us go back to questions. I am in an Oxford university study in England looking at Oregon damage. One third of those tested so far have Oregon damage. Do you have a sense of whether or not this will be permanent,


Right? I don’t. I need more specifics. So when you say Oregon damage, what does that mean? And how is it being tested?


I can explain it because it’s actually me again. Sorry. I don’t mean to,


Yeah. Don’t try to take the whole meeting over. Okay. Listen, I’m just trying to stage a Crow, a COO from overseas. Go ahead.


So I’m in an Oxford university trial amongst others. I’m in several trials cause I’m in the UK. I’m one of the very earliest, if not the earliest, I got it on the 25th of December, Christmas day, I couldn’t taste my food. But I wasn’t actually in the UK then anyway. So in this study it’s called the cover scan study. They use a very special type of liver monitor, which is it’s called letter scan or cover scam. It’s a new type of technology, but effectively there’s 500 of us and we have a full MRI. But we also have this special scan that looks at the organs in great detail in terms of looking at the fibrous areas of the organ, looking at the organs, how they are able to pump I’ve got the heart, for example, how it’s pumping the oxygen, the water, sorry, the blood all the way through.


So it is much more detailed, but they don’t provide us with a one by one result. They give us the graphs and the UN all the technical stuff. And then you have to go and find somebody to interpret it. Or you have to go on Google and try and do it yourself. So I was told, for example, I I’ve had it eight months now. COVID-19, I’m still unwell. I still got laryngitis. As you can hear. I’m not just Barry white. But I’ve got three lesions on my liver. I’ve got damage to my mitral heart valve. And I’ve got a problem with my spleen that is enlarged. And those are three out of the six organs that I’ve so far got feedback on. But it’s just in a case of a scan and they take lots of blood. So my neutrophil level is way down. I’ve got a rouleaux blood stuff coming out. I’ve got very, very high. Okay.


Hang on one second. Do you have enough information, dr. Mccarthy based on that?


Well, I have enough information to say that it’s very hard for me to weigh in on that. Right. So


You’ve got, you’ve crossed the line. You’ve got too much information at this point, right.


I just in here, so circling back around, right. Like I have to be presented with this study where I don’t really understand how they’re testing things and what they’re looking at. And also to say, if you’re doing imaging on somebody you know, unless there’s certain markers that they have where they, they understand that those are effects are secondary to COVID, that’s one thing. Right. But I, I not knowing the study, I don’t know how they, how they interpret that. Right. So, but what I would say, you know, you take imaging on anybody and you do a full body scan. You’re going to have incidental findings there. And not to say that that’s what this is, but that, that also can’t be ruled out. So I don’t know. Right. So I don’t know if they have some sort of covert specific markers. But I can’t really weigh in on that because I’m not a part of that study a and B I don’t know of anything here that we’re doing at least at and I, or that we’ve come across in terms of our research in the States looking at that. So, okay.


Would you be comfortable giving that a definite maybe


Paragraph the UK daily Telegraph, I can share it or whatever is the results so far of this big organ study in the UK, from Oxford university, it is fascinating.


It’s cover scam and it’s done Oxford university. If you just look at the daily Telegraph website, you’ll find it.


Yeah. So I, so I always hesitated to, and I say this to patients as well on I, so unless it’s a, I’m getting an IRB or something, right. I wouldn’t look at an article that’s written up by a news organization. Right. Because they’re, they’re presenting information that in an unscientific way, in the sense that, that there’s so much stuff coming out. Right. And that’s the problem with all of this. And again, I am not not saying anything to determine, you know, what the study has shown for your hasn’t, but I can’t weigh in on that because I don’t know. Right.


You’re entitled. I noticed a new symptom pre COVID. I could get my heart rate to one twenties to one forties during exercise. I got an exercise bike and couldn’t get my heart rate above the low nineties.


Yeah. So I would say to that individual I mean, depending on a lot of other factors, have they been seen by a cardiologist is the resting heart rate going even lower than that? So those are, those are things to just have investigated if your heart rate is not going up.


It’s it’s me and my resting heart rate was when I was healthy about 60 it’s in the 70 range now. So I’ve just got this narrow range of at rest. It’s pretty close to the maximum. I can get it to, I have seen a cardiologist, but the tests they’ve done so far don’t show anything. They haven’t done a stress test, but everything had done resting. Yeah.


Yeah. I would say that a stress test is probably a good idea in this case. Yeah. Because that’s when the, you know, that stuff that kind of lack of increase right. In proportion to exertion is not happening. So they would need to look at that for you. Okay.


Thank you, Evan. Can I ask if you take any cardiac medications? No. I’ve never had a heart condition in my life. I was very healthy heart wise. I have a neurological condition that doesn’t affect the heart. As far as I know, I would love, I’m sorry. I can’t start my video. The camera’s broken on this computer. That’s okay. But I can move my mouth while you speak, but that’s, that’s it, I never really had a reason to have harder alone issues before.


Right. So again, not knowing your full, complete history and background, which again is not appropriate for the setting. So I don’t, I don’t want that. But I would say, you know, if you do to, to follow up with the specialists that you follow for your underlying conditions and just kind of circle around that and make sure that there is not the possibility of something else being implicated there for you. Okay.


And, and I think your suggestion about asking for a stress test from the cardiologist is a good one at all. Follow up. Yeah. I mean, if, you know, if you want to know what your, your, your, your, a plane does in the air, like you can’t test it on the ground before you take off and on the ground after you land, you have to see it in action. What, just one more question, is it possible that you’re working out at a lower rate or a lower intensity because of, of, of your overall condition right now? Very deleterious. Very definitely. I mean, I am, I mean, I’m doing the workout I expected to do 30 years from now. Now it’s like, I just can walk in the park and that’s kind of a workout now, but I went for a physical therapy session and they put me on an exercise bike, and I did it really low just to see if I could do it.


And they had an you know, they check your pulse. And I realized when I felt like my heart rate was in the one tens one twenties, like when I was really what I thought I was pumping, it was 91. Yep. And that’s, I’d say that was, what’s a surprise for me. And I just figured I’d try to react to it. Try to get, try to learn what that means. Yeah. So, dr. Mccarthy, I’m sorry, go ahead. No, that’s okay. Please. What would you say to somebody who would say this has taken over their lives, where they live their lives?


Yeah, I would say I would say if that’s the case, then first and foremost, reaching out to try to get some help in terms of support whether that be a therapist, right. If they don’t already have one in terms of no matter where you are country, state, whatnot there, there are always I think help hotlines that you can kind of call if you’re, if you’re unsure of where to start, your hospital could be, could be one, you call it the hospital system and to say, you know, I’m in need of some assistance that way. I hopefully, you know, if you’re, you’re in New York and that’s a problem for you reaching out to your, or anywhere, I guess, reaching out to your primary care doctor, your GP is also a good place to start with that. In terms of, of getting connected with somebody who can help you through that,


I would also invite you to our Sunday night meetings that we have with Lori Nadel, who is a PhD psychologist and Erica master bono, who is a social worker. And, you know, again, I would just caution people from, you know, jumping on Facebook and sort of commiserating because that is just, you know, it’s like, you can have this sort of cycle of, you know, stress.


Here’s what I guide patients to do. Because it can be kind of be, like I said, a rabbit hole was one, you guys are all in this together. Right. So so you kind of have a choice in terms of how the narrative goes and trying to, to infuse a thread of optimism in there. Right. And instead of honing on how bad the you’re feeling, I would love to see some, some discussion around how things have improved, right. So it’s good to look at everything, right? Not just the negatives, but also the positives in terms of where you come. However small that might be right, because that’s important. The second thing is for your own mental health, all of us, right? Limit the amount of time that you’re spending on those, you know, in chat rooms and on Facebook and different things like that. I like to say, give yourself 30 minutes a day, same time every day. That’s when you allow yourself to log in. Otherwise you have to be able to put that out of the mind and focus on yourself. And that is one of the most important things that you can do for yourself.


Somebody wrote, I was referred to you directly by dr. Mccarthy. I am her patient. And I just want to say, I’m not afraid. So bring it on. How can we get more post COVID care centers to open? So longterm care can be given to more suffers. I live in LA and if I am correct, I don’t do not think there is a center nearby. If this is true, that’s awful considering how horribly LA has been as far as COVID numbers.


I mean, we’re trying our best. So I am what we say at Mount Sinai is our tools are your tools. So we are, we don’t do anything that is Sinai branded in the sense that this, our protocol or whatnot. I have spoken with many individuals around the country who are trying to get these sort of treatment programs up and running. And we are happy to share our knowledge with any other medical facility in that regard. So that’s the best that we can do. You know, again, it’s just, I think it’s, I’m trying to seek out those who may be open to helping you on an individual level, if you feel like there’s no center out there. So be it a primary care physician, be it a physiatrist be it a therapist that, you know, physical therapist anybody, right? So any care provider that you think is, is open or inspired to, to help and do something, right. Please give them our names. We’re happy to speak to them and try to try to get things going in that regard. So it’s about working together and sharing information.


Absolutely. And we’re, you know, we’re doing consultations with patients through our foundation. You could say, I’m sorry, covert And we’re happy to pass the information along. We’re now also working with Sinai. So, you know, there’s no one here that’s kind of trying to keep their cards close to their chest. We’ve been pretty open with sharing information. Dr. McCarthy, what about posts? How do you get past post exertional malaise?


Yeah, that’s, that’s part of this whole continuum, right. And that takes time. So the first thing first and foremost with any of this is, is, like I said, is optimizing all the different systems and getting started with breath work, breath work is the first and foremost step number one.


Have you seen a pattern of shingles in post COVID patients?


I have not, but again shingles can be induced by any type of stress on the body. So it’s possible.


Marissa, I can’t unmute myself. Are you seeing that as a common post COVID center symptom and you can’t wait, you just muted yourself. You were playing possum, so you could get on the show. Go ahead. What’s your question. Hi, doctor.


I was just wondering, I didn’t ask this during our appointment, but has Mount Sinai thought of addressing the mental health portion of the illness? Yeah, so we’re, we’re definitely working hard to do that. Is a great question. So right now our psychology department is really gearing up in creation right now is a group support system that will hopefully be available soon. Meaning in the next one to two weeks as well as trying to make sure that we have care providers available for individuals and, you know, regardless of insurance, which obviously that comes at a very difficult thing. So everybody can get the support that they need. Right. So twofold group support as well as individual support. Cause it is such a huge component


When I do see you feel free to unmute going, yes, you got it. You try that trick is Marissa. Can you hear me? Yes. The question is for people with blood cancers, such as MGUS, M cursed multiple myeloma for people like us, who’ve had COVID what would be your suggestions first for the future as it cost per question for us?


Yeah. So I, I, one would hope that you’re following very closely with your key monk, right? Your hematologist oncologist. And, and for you, that’s gonna definitely require a closer monitoring in terms of your blood work. Right. So I don’t know. And again, are you calling in from the UK? Are you in the United States?


No, no, I’m quite from the UK.


Okay. So, you know, your, your house system runs very differently than ours, right? I don’t know how long it takes you to get in, to see a hematologist or oncologist. But have you,


Well, I haven’t seen my hematologist for about four months now, so it’s quite difficult.


Yeah. And that’s, you know, I obviously can’t help you in that regard, but I do think it’s important that you follow up with them a bit more closely,


But do you think there is a link between the two and other problems that may come along and the long one, or do you think there’s not really a strong bias there


Again, not enough time has gone by to be able to say that. Right. So it’s possible in terms of the fact that it can affect different levels in your blood. Right. We know that and being a cancer in and of itself, right. Puts you at a risk for different things like a hypercoaguable state, so to speak. So that’s why I’m saying to you for in your case, it’s definitely important that you follow up with your hematologist. That way they can be, you know, maybe running tests a little bit more frequently for you just to make sure that nothing’s changing. Right. All of this it’s a novel virus. Right. So we, we don’t know. So I can’t sit here and say to you, Oh yes. Yep. Absolutely. because the time hasn’t gone by for us to see how people are being affected. Right. And we’re still trying to understand the pathophysiology behind the virus and what those implications are in terms of, of the effects on the system.


Oh, yes, of course. I totally understand that. So you mentioned that you don’t consider this dysautonomia. Many people have been given a diagnosis of pots. So do you feel that that’s a premature




No, not necessarily. So pots is very specific to, to get that, so pots, right. So everyone understands, we’re talking about Don postural, orthostatic tachycardia syndrome. Yeah. So meaning when you send up right. Your heart rate races, because cause your systems are dysregulated and they’re trying to, to prompt. So your heart rate is pumping quicker to try to get that going. That said usually that diagnosis is made with some objective measures, be it till tests or usually till tests, but sometimes they can use a NASA lean test, that sort of thing. But if somebody is giving a diagnosis of pots, it’s kind of just a general one again, I refuse to use labels. So unless it specifically fits that criteria I wouldn’t necessarily call it. I make my may say it’s pots, like right. But I, I wouldn’t, and again, it’s a syndrome, right. So when we talk about syndromes, when we’re talking about chronicity and we’re talking about something that that is not necessarily going to resolve, you’re just going to minimize the effects from it.


I noticed you picked up a bit of a British accent after hearing Glenn speak. Is that on purpose? I noticed you tend to mimic the others. So someone said she’s my doctor currently. And I really enjoy working with her. That’s nice to hear. And what about are you seeing six? Are there any, let’s just say arrhythmias in general. Are there any arrhythmias you’re seeing more than others besides like a sinus tachycardia? Nope. Not more a AFib. Nope. No sick sinus syndrome. Nope. I’m going to name every written.


Go for it.


You to say it with a different accent every time. What about a first degree blocks? Nope. That’s the same accent you just used before. Alright, so let’s see. Marissa Oliver, thanks for the input. I am excited. You’re a dancer and live in Brooklyn, right? We have a lot in common and now adopter. All right. I think it’s time for a Jeffery ladies and gentlemen. I am having breathing difficulty recently due to a block blocked airway and the nose. Are there any suggestions for a relief?


So I I’m actually gonna hesitate on answering specific questions like this, just because I am not serving as people’s medical doctor in this, in this forum. Right. So that, that, it’s not really appropriate for me to do. I know I’ve, I’ve given a little bit out there, but I again, I, I want people to kind of go back to their primary care and, and talk about that. I’m okay. Talking about generalities there, but I, I can’t treat patients specifically or give answers.


Sure. This is also kind of a specific question, but if you were really tired and had to opt for a five hour energy, would you generally go for the grape, the peach or the lemon lime?


I I’ve never had a five hour energy. I don’t know. Yeah.


I know what you’re missing. You should try this. This is awesome. Dr. McCarthy, I saw you virtually for my intake for the covert precision recovery program. I just wanted to thank you for your care during a very stressful time for me, that’s from Mick. It would help those of us who combine lip reading with hearing if the guests




Okay. That, that will work out in post production. Okay. Other things is node something that is being seen in many post COVID patients?


No, but if you have renounce and exacerbation of that is certainly something that could happen.


Went back to the UK again for that one. I see. Okay. So I think that that’s it, I’m going to give you two minute warning. I’ll give you a little opportunity for speed round. If anybody has another question, Wendy, you can unmute, but I’m going to just remind everybody of the rules. If you try to in any way, stage a coup, as Nick found out before the first time we will mute you the second time we will boot you. So speak carefully, Wendy, go ahead. Choose your words wisely.


Okay. So my, my question is around fever. Have you seen people with very prolonged fever, fevers that change up during the day? And are, are people generally actually treating for it or not? I’ve had a fever between a hundred 0.6 and 103 it lower in the morning goes up in the afternoon, one Oh one, one Oh two and then the big ones at night when I go to bed at seven. Cause I can’t stand it, but I’ve only taken Tylenol like three times the rest of the time. I’m just letting my body fight it. I’m wondering, have you seen a lot of that because it’s been 182 days of fever? Yeah, so not, no, not fever that high like that. And I, I definitely would say to you, if you, have you seen an infectious disease doctor or anybody an immunologist in that regard? I I’ve been out of my house twice since February 20th, once was to ER for the x-ray that showed the pneumonia. And the other one was two days ago to get a Holter and a CT scan of full chest CT and more blood work and a CRP and Ana, which were off the charts. So so I, I really think that there definitely is more investigative work that needs to be done.


Fevers that high are not good for you. Right. Prolonged fevers when it’s getting up to 103 and things like that. So yeah, I would put that on your priority list in terms of going to see probably a infectious disease doctor writes, we, we talk about COVID is kind of overwhelms the conversation. Right. But there’s also possibility that you could have a secondary infection or something like that. Right. And you don’t want to miss things like that. So I definitely say to you, please, as soon as you can try to try to either reach out to your primary care doctor to be connected with somebody who can help you with in regards to high fevers. Yeah.


All she said was, Oh wow. Really? But they’re not willing to give any referrals, so.


Okay. I’m really sorry.


I don’t know. But yeah. So you haven’t seen that that’s not,


Not that high. So I definitely see a lot of patients overtly having a fever, meaning their temperature. Doesn’t go above a hundred 0.3, right. As we clinically define a fever yet their body temperature feels feverish. So there’ll be feeling very hot at times, almost like hot flashes, right? Like their body becomes very hot and either that can be at night, it could be during the day. It can be when they’re having that feeling of like an exacerbation of their symptomatology. So that very often but again, not to those degrees. And like I said, I do encourage you to, to keep trying to get, to get, to see somebody for that.


I should clarify the first six weeks in the evening, it went up to [inaudible] then the following two months, it was in the one Oh twos at night. And then this last six or seven weeks it’s in the high one. Oh. Ones that I think I’ve had three or four, one Oh twos. So it is incrementally coming down, but it’s been every day for 182 days. I’m on the Southern Oregon coast.


Okay. Again, I, I do think and you’ve seen a cardiologist.




Okay. So, so the primary care was doing the cardiac workout.


If that’s what you want to call it, they did an EKG and they gave me as IO for seven days. And if they don’t catch anything another seven days, she said that that would have to show something in order to get an echo typewriter, what echocardiogram, excuse me.


Oh, good. Yeah. Again, I think that you need to be seen by a specialist because high fevers that prolonged that hire are not, not appropriate nor are they seeing in terms of coven,


Amy, last question of the evening, go for it. You’ve been very patient. So I’m going to give you a full hour. Okay,


Awesome. I’ll take that full hour.


No one else is going to be here when you finished, but go for it.


Most of my symptoms are, can you hear me? Yeah. Most of my symptoms are Desota NAMEC on tacky hypoxic and I have GI symptoms. Had a cardiac workup. I’m good. As far as echo and Holter monitor, but internal medicine really doesn’t think it’s COBIT because my testing was negative. I had three nasal swabs and two antibodies about a month apart. So they think it’s more post viral, but that not COVID since, but my motto and parvo was negative, but that sounds so cute. He’s like a hundred percent convinced that if you have antibody tests a month apart and they’re negative, then you definitely don’t have COBIT. So what has your experience there been? Yeah, so from our perspective, right? None of our testing is fail proof. Right, right. So, so that said, and again, we still don’t understand enough about how the immune system is responding to this.


And some of the investigative work is showing indications that there is a very different type of response tend to depending potentially on the gender and depending on your, your other factors that are involved. So from our perspective, a test doesn’t mean anything. So if you had symptoms that aligned with Colvin, right, and you still are presuming it to be such, that said it’s a viral infection. Now, so for us, whether you had COVID or you had another virus, our goal is to get you better. Right. now again, we don’t understand enough about Hoving to be treating patients who had COVID or even if they had a different virus and didn’t know that and are feeling symptoms differently right now. Right. So if they’re having this picture of autonomic, dysregulation are, our inputs are the same. So and I know, and there’s, there’s a lot that’s caught up in rhetoric.


So and I can’t speak for other providers and what this means. It is going to be an issue in the future, right. Until we understand more about it. And, and hopefully it can come up with either better tests or objective measures that say whether, you know, whether you did have it, we can identify, but you know, a PCR testing, meaning the nasal swab and the antibody testing again are not a hundred percent sensitive or specific in any way. So right now we being patient centric are not focused on that. So, so as long as that’s not preventing you from getting care to try to feel better, right. I wouldn’t, I wouldn’t let that impact you so much. And again, you know, I would say that two twofold, right? So if somebody is telling you, this is all in your head, right. You’re crazy. That is not the appropriate response, right. You’re not feeling well and you need help in terms of feeling better. But you know, also whether, whether you had a positive test or not, at least from our perspective and the way I approach a patient, that doesn’t change.


Yeah. It makes it so tricky when the test seems so unreliable, it’s, you know, it’s such a tough position to be.


Yeah. And when the medical field is putting so much, so much emphasis on that, right. And it’s, it’s becoming how they dictate their pathways, but all of this is, is is very complicated from many different viewpoints. Right. So I would almost say for all the UK listeners out there, I am interested to see what happens there as a national health system, where they don’t have some of these obstacles where, where it’s a little bit more open towards, towards interpretation in a sense that the tests are not, you know, fail-proof right. So but right now in the United States unfortunately things are, are, are guided by sometimes. So ulterior motives in a sense and because we’re just desperately trying to do stuff to make patients feel better and get better and identify patients and control an outbreak. And these are the tools that we have, right?


So we kind of, in some ways have to put some, you know, some stock in but in terms of the chronic symptoms, it does become an issue. And again, that’s where, that’s where me doing this work was born up, right. Is the acceptance of patients were not only tested positive in one way or another, but those who haven’t right. And experienced an illness and are suffering from that. Which until proven otherwise, right. I would say is probably coping, right. There’s going to be a small percentage of patients where it probably, it might not have been, and that’s a very small percentage.


And you brought up a great point, you know, in that sequence, which was that just because you have COVID doesn’t mean that you can’t have something else going on. So when in doubt, err, on the side of caution and I, I think that’s a great place to stop dr. Mccarthy, thank you so much for being here. And if anybody would like to reach out please feel free and we’re going to unmute everybody so that we can give you the auditory version of. Thank you. So thank you so much. It’s been great. Thank you so much. Thank you. And I’m just curious, when I come in from my aesthetic procedures, will that be in office or will that be like remote? Oh, definitely remote. Yeah. I don’t blame you have a great night and thank you so much.


Love you.